Clinical Physiology of Circulation

ISSN 1814-6910 (Print)
ISSN 2410-9134 (Online)

 

Chief Editor

Leo A. Bockeria, MD, PhD, DSc, Professor, Academician of Russian Academy of Sciences, President of Bakoulev National Medical Research Center for Cardiovascular Surgery


Issue's catalogue ➤ КФК. 2022; 19 (4): 287-392 ➤ Выбор стратегии инфузионной терапии при операциях аортокоронарного шунтирования без искусственного кровообращения

Choice of strategy of infusion therapy in off-pump coronary artery bypass

Authors: Khinchagov D.Ya., Rybka M.M., Mumladze K.V., Golubev E.P., Yudin G.V., Aidashev Yu.Yu., Vorozhka I.V.

Company:
Bakoulev National Medical Research Center for Cardiovascular Surgery, Moscow, Russian Federation

E-mail: Сведения доступны для зарегистрированных пользователей.

DOI: https://doi.org/10.24022/1997-3187-2022-16-3-340-354

UDC: 616.12-005.4-036.12-089.86:615.451.232

Link: Clinical Physiology of Blood Circulaiton. 2022; 4 (19): 338-348

Quote as: Khinchagov D.Ya., Rybka M.M., Mumladze K.V., Golubev E.P., Yudin G.V., Aidashev Yu.Yu., Vorozhka I.V. Choice of strategy of infusion therapy in off-pump coronary artery bypass. Clinical Physiology of Circulation. 2022; 19 (4): 338–48 (in Russ.). DOI: 10.24022/1814-6910-2022-19-4-338-348

Keywords:  fluid therapy off-pump coronary artery bypass

Received / Accepted:  18.07.2022 / 12.10.2022

Full text:  

Abstract

Objective. To compare the effect of restrictive, liberal and goal-directed fluid therapy on the course of intraoperative and postoperative periods and the duration of mechanical ventilation in off-pump coronary artery bypass (OPCAB).

Material and methods. A single-center retrospective study that included 152 OPCAB patients operated between 2017 and 2018. All patients were divided into 3 groups depending on the strategy of infusion therapy: group 1 with restrictive infusion therapy (RIT) – 48 patients (intraoperative balance (IB) – up to 700 ml), group 2 with liberal infusion therapy (LIT) – 68 patients (IB – from 2200 ml), group 3 goal-directed fluid therapy (GDIT) – 36 patients (IB was – 1207 ± 663 ml). A comparison was made of the oxygenating function of the lungs, the concentration of serum lactate, biochemical parameters and the duration of mechanical ventilation. In the GDIT group, infusion therapy was performed under the control of central hemodynamic data.

Results. According to the results of our study, there were no differences between the groups in the values of arterial oxygen partial pressure (PaO2) in the intraoperative period. At initial values in the groups: RIT – 297.4 ± 95.6, LIT – 288.1 ± 83.3, GDIT – 297.3 ± 94.4 (p = 0.822); there was a statistically insignificant improvement in oxygenation in all groups: RIT – 311.1 ± 91.9, LIT – 298.8 ± 80.9, GDIT – 319.8 ± 80.4 (p = 0.457). Intergroup comparison of statistically significant difference in the duration of mechanical ventilation (h) was not obtained: RIT – 5.0 (4.0; 8), LIT – 6.0 (5.0; 9) and GDIT – 5.0 (4.0; 9). The indicators of serum lactate (mmol/l) by the time of the skin suture were within the permissible values: RIT – 1.4 (1.1; 1.8), LIT – 1.6 (1.2; 2.1) and GDIT – 1.2 (0.9; 1.5). Analysis of venous saturation data (SvO2): RIT – 75.2 ± 7.2, LIT – 76.5 ± 10.2 and GDIT – 76.5 ± 8.4 (p = 0.616); which indicates an adequate level of oxygen delivery, regardless of the strategy of infusion therapy.

Conclusion. The strategy of infusion therapy for OPCAB, with minimal blood loss, does not affect the course of intraoperative and postoperative periods and the duration of ventilation. Stable hemodynamics is the key to providing adequate anesthesia, regardless of the tactics of infusion therapy.

References

  1. Grocott M.P.W., Mythen M.G., Gan Perioperative T.J. Fluid Management and Clinical Outcomes in Adults. Anesthesia & Analgesia. 2005; 100 (4):1093–106. DOI: 10.1213/01.ANE.0000148691.33690.AC
  2. Navarro L.H., Bloomstone J.A., Auler J.O., Cannesson M., Rocca G.D., Gan T.J. et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioperative Medicine. 2015; 4 (1): 3. DOI: 10.1186/s13741-015-0014-z
  3. Kapoor P.M., Magoon R., Rawat R.S., Mehta Y., Taneja S., Ravi R. et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann. Card. Anaesth. 2017; 20 (1): 83–9. DOI:10.4103/0971-9784.197842
  4. Miller T.E., Myles P.S. Perioperative fluid therapy for major surgery. Anesthesiology. 2019; 130: 825–32. DOI: 10.1097/ALN.0000000000002603
  5. Гирш А.О., Какуля Е.Н., Иванов К.А., Ушакова Н.Г., Чугулев И.А., Шакирова З.А. Интраоперационная инфузионная терапия. Сибирский медицинский журнал. 2013; 1: 29–33.
  6. Al-Ghamdi A.A. Intraoperative fluid management: past and future, where is the evidence? Saudi J. Anaesth. 2018; 12: 311–7. DOI: 10.4103/sja.SJA_689_17
  7. Кравец О.В., Клигуненко Е.Н. Оптимальный режим периоперационной инфузии: за и против. Медицина неотложных состояний. 2019; 3 (98): 14–20.
  8. Diaper J., Schiffer E., Barcelos G.K., Luise S., Schorer R., Ellenberger C. et al. Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: a randomized controlled trial. Surgery. 2021; 169: 1164–74. DOI: 10.1016/j.surg.2020.09.035
  9. Della Rocca G., Vetrugno L., Tripi G., Deana C., Barbariol F., Pompei L. Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach? BMC Anesthesiol. 2014; 14: 62–74. DOI: 10.1186/1471-2253-14-62
  10. Яворовский А.Г. Специфические компоненты анестезиологического обеспечения операций реваскуляризации миокарда. В кн.: Бунятян А.А., Трекова Н.А. (ред.) Руководство по кардиоанестезиологии. М.: ООО «Медицинское информационное агентство»; 2005.
  11. Черний В.И. Сбалансированная инфузионная терапия в периоперационном периоде. Методы жидкостной ресусцитации периоперационной кровопотери. Медицина неотложных состояний. 2015; 2: 37–43.
  12. Vincent J.L., Pelosi P., Pearse R., Payen D., Perel A., Hoeft A. et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit. Care. 2015; 19 (1): 224. DOI: 10.1186/s13054-015-0932-7
  13. Kendrick J.B., Kaye A.D., Tong Y., Belani K., Urman R.D., Hoffman C. et al. Goal-directed fluid therapy in the perioperative setting. J. Anaesthesiol. Clin. Pharmacol. 2019; 35: 29–34. DOI: 10.4103/joacp.JOACP_26_18
  14. Miller T.E., Roche A.M., Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can. J. Anaesth. 2015; 62 (2): 158–68. DOI: 10.1007/s12630-014-0266-y
  15. Pestaña D., Espinosa E., Eden A., Nájera D., Collar L., Aldecoa C. et al. Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth. Analg. 2014; 119 (3): 579–87. DOI: 10.1213/ANE.0000000000000295
  16. Ackland G.L., Iqbal S., Paredes L.G., Toner A., Lyness C., Jenkins N. et al. POM-O (Postoperative Morbidity-Oxygen delivery) study group. Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial. Lancet Respir. Med. 2015; 3 (1): 33–41. DOI: 10.1016/S2213-2600(14)70205-X
  17. Pearse R.M., Harrison D.A., MacDonald N., Gillies M.A., Blunt M., Ackland G. et al. OPTIMISE Study Group. Effect of a perioperative, cardiac outputguided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014; 311 (21): 2181–90. DOI: 10.1001/jama.2014.5305
  18. Хинчагов Д.Я., Рыбка М.М. Центральная гемодинамика при операциях реваскуляризации коронарных артерий без искусственного кровообращения. Клиническая физиология кровообращения. 2021; 18 (3): 201–11. DOI: 10.24022/1814-6910-2021-18-3-201-211
  19. Joshi G.P. Intraoperative fluid management. UpToDate. 2020.
  20. Shin C.H., Long D.R., McLean D., Grabitz S.D., Ladha K., Timm F.P. et al. Effects of intraoperative fluid management on postoperative outcomes: a hospital registry study. Ann. Surg. 2018; 267: 1084.
  21. Thacker J.K., Mountford W.K., Ernst F.R., Krukas M.R., Mythen M.M. Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Ann. Surg. 2016; 263: 502–10.
  22. Marik P.E., Baram M., Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008; 134: 172–8.
  23. De Backer D., Vincent J.L. Should we measure the central venous pressure to guide fluid management? Ten answers to 10 questions. Crit. Care. 2018; 22 (1): 43. DOI: 10.1186/s13054-018-1959-3
  24. Romagnoli S., Rizza A., Ricci Z. Fluid status assessment and management during the perioperative phase in adult cardiac surgery patients. J. Cardiothorac. Vasc. Anesth. 2016; 30 (4): 1076–84. DOI: 10.1053/j.jvca. 2015.11.008
  25. Shahidi Delshad E., Sanadgol H., Bakhshandeh H., Saberian M., Alavi S.M. Fluid balance has effects on the length of hospital stay after coronary artery bypass grafting surgery. Iran J. Kidney Dis. 2020; 14 (1): 36–43. PMID: 32156840
  26. Сметкин А.А., Киров М.Ю. Мониторинг венозной сатурации в анестезиологии и интенсивной терапии. Общая реаниматология. 2008; 4 (4): 86–90.
  27. Sirivella S., Gielchinsky I. Hemodynamic changes during off-pump coronary artery bypass graft surgery: experience using pericardial bands for target stabilization. World Journal of Cardiovascular Surgery. 2013; 3: 227–33.
  28. Bilotta F., Rosa G. Optimal glycemic control in neurocritical care patients. Crit. Care. 2012; 16 (5): 163.
  29. Schricker T., Sato H., Beaudry T., Codere T., Hatzakorzian R., Pruessner J.C. Intraoperative maintenance of normoglycemia with insulin and glucose preserves verbal learning after cardiac surgery. PLoS One. 2014; 9 (6): 99661.
  30. WenKui Y., Ning L., Jianfeng G., Weiqin L., Shaoqiu T., Zhihui T. et al. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Surgery. 2010; 147 (4): 542–52. DOI: 10.1016/j.surg.2009.10.036
  31. Foucher C.D., Tubben R.E. Lactic Acidosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. PMID: 29262026.
  32. Kalmar A.F., Allaert S., Pletinckx P., Maes J.W., Heerman J., Vos J.J. et al. Phenylephrine increases cardiac output by raising cardiac preload in patients with anesthesia induced hypotension. J. Clin. Monit. Comput. 2018; 32: 969–76. DOI: 10.1007/s10877-018-0126-3
****
  1. Grocott M.P.W., Mythen M.G., Gan Perioperative T.J. Fluid Management and Clinical Outcomes in Adults. Anesthesia & Analgesia. 2005; 100 (4):1093–106. DOI: 10.1213/01.ANE.0000148691.33690.AC
  2. Navarro L.H., Bloomstone J.A., Auler J.O., Cannesson M., Rocca G.D., Gan T.J. et al. Perioperative fluid therapy: a statement from the international Fluid Optimization Group. Perioperative Medicine. 2015; 4 (1): 3. DOI: 10.1186/s13741-015-0014-z
  3. Kapoor P.M., Magoon R., Rawat R.S., Mehta Y., Taneja S., Ravi R. et al. Goal-directed therapy improves the outcome of high-risk cardiac patients undergoing off-pump coronary artery bypass. Ann. Card. Anaesth. 2017; 20 (1): 83–9. DOI:10.4103/0971-9784.197842
  4. Miller T.E., Myles P.S. Perioperative fluid therapy for major surgery. Anesthesiology. 2019; 130: 825–32. DOI: 10.1097/ALN.0000000000002603
  5. Girsh A.O., Kakulya E.N., Ivanov K.A., Ushakova N.G., Chygylev I.A., Snacirova Z.A. Intraoperative infusion therapy. Siberian Medical Journal. 2013; 1: 29–33 (in Russ.).
  6. Al-Ghamdi A.A. Intraoperative fluid management: past and future, where is the evidence? Saudi J. Anaesth. 2018; 12: 311–7. DOI: 10.4103/sja.SJA_689_17
  7. Kravets O.V., Kligunenko E.N. Optimal regimen of perioperative infusion: pros and cons. Emergency Medicine. 2019; 3 (98): 14–20 (in Russ.).
  8. Diaper J., Schiffer E., Barcelos G.K., Luise S., Schorer R., Ellenberger C. et al. Goal-directed hemodynamic therapy versus restrictive normovolemic therapy in major open abdominal surgery: a randomized controlled trial. Surgery. 2021; 169: 1164–74. DOI: 10.1016/j.surg.2020.09.035
  9. Della Rocca G., Vetrugno L., Tripi G., Deana C., Barbariol F., Pompei L. Liberal or restricted fluid administration: are we ready for a proposal of a restricted intraoperative approach? BMC Anesthesiol. 2014; 14: 62–74. DOI: 10.1186/1471-2253-14-62
  10. Yavorovskiy A.G. Specific components of anesthetic management of myocardial revascularization operations. In: Bunyatyan A.A., Trekova N.A. (Eds.) Guide to Cardioanesthesiology. Moscow; 2005 (in Russ.).
  11. Cherniy V.I. Balanced infusion therapy in the perioperative period. Methods of liquid resuscitation of perioperative blood loss. Emergency medicine. 2015; 2: 37–43 (in Russ.).
  12. Vincent J.L., Pelosi P., Pearse R., Payen D., Perel A., Hoeft A. et al. Perioperative cardiovascular monitoring of high-risk patients: a consensus of 12. Crit. Care. 2015; 19 (1): 224. DOI: 10.1186/s13054-015-0932-7
  13. Kendrick J.B., Kaye A.D., Tong Y., Belani K., Urman R.D., Hoffman C. et al. Goal-directed fluid therapy in the perioperative setting. J. Anaesthesiol. Clin. Pharmacol. 2019; 35: 29–34. DOI: 10.4103/joacp.JOACP_26_18
  14. Miller T.E., Roche A.M., Mythen M. Fluid management and goal-directed therapy as an adjunct to Enhanced Recovery After Surgery (ERAS). Can. J. Anaesth. 2015; 62 (2): 158–68. DOI: 10.1007/s12630-014-0266-y
  15. Pestaña D., Espinosa E., Eden A., Nájera D., Collar L., Aldecoa C. et al. Perioperative goal-directed hemodynamic optimization using noninvasive cardiac output monitoring in major abdominal surgery: a prospective, randomized, multicenter, pragmatic trial: POEMAS Study (PeriOperative goal-directed thErapy in Major Abdominal Surgery). Anesth. Analg. 2014; 119 (3): 579–87. DOI: 10.1213/ANE.0000000000000295
  16. Ackland G.L., Iqbal S., Paredes L.G., Toner A., Lyness C., Jenkins N. et al. POM-O (Postoperative Morbidity-Oxygen delivery) study group. Individualised oxygen delivery targeted haemodynamic therapy in high-risk surgical patients: a multicentre, randomised, double-blind, controlled, mechanistic trial. Lancet Respir. Med. 2015; 3 (1): 33–41. DOI: 10.1016/S2213-2600(14)70205-X
  17. Pearse R.M., Harrison D.A., MacDonald N., Gillies M.A., Blunt M., Ackland G. et al. OPTIMISE Study Group. Effect of a perioperative, cardiac outputguided hemodynamic therapy algorithm on outcomes following major gastrointestinal surgery: a randomized clinical trial and systematic review. JAMA. 2014; 311 (21): 2181–90. DOI: 10.1001/jama.2014.5305
  18. Khinchagov D.Ya., Rybka M.M. Central hemodynamics in coronary artery revascularization operations without cardiopulmonary bypass. Clinical physiology of blood circulation. 2021; 18 (3): 201–11 (in Russ.). DOI: 10.24022/1814-6910-2021-18-3-201-211
  19. Joshi G.P. Intraoperative fluid management. UpToDate. 2020.
  20. Shin C.H., Long D.R., McLean D., Grabitz S.D., Ladha K., Timm F.P. et al. Effects of intraoperative fluid management on postoperative outcomes: a hospital registry study. Ann. Surg. 2018; 267: 1084.
  21. Thacker J.K., Mountford W.K., Ernst F.R., Krukas M.R., Mythen M.M. Perioperative fluid utilization variability and association with outcomes: considerations for enhanced recovery efforts in sample US surgical populations. Ann. Surg. 2016; 263: 502–10.
  22. Marik P.E., Baram M., Vahid B. Does the central venous pressure predict fluid responsiveness? A systematic review of the literature and the tale of seven mares. Chest. 2008; 134: 172–8.
  23. De Backer D., Vincent J.L. Should we measure the central venous pressure to guide fluid management? Ten answers to 10 questions. Crit. Care. 2018; 22 (1): 43. DOI: 10.1186/s13054-018-1959-3
  24. Romagnoli S., Rizza A., Ricci Z. Fluid status assessment and management during the perioperative phase in adult cardiac surgery patients. J. Cardiothorac. Vasc. Anesth. 2016; 30 (4): 1076–84. DOI: 10.1053/j.jvca. 2015.11.008
  25. Shahidi Delshad E., Sanadgol H., Bakhshandeh H., Saberian M., Alavi S.M. Fluid balance has effects on the length of hospital stay after coronary artery bypass grafting surgery. Iran J. Kidney Dis. 2020; 14 (1): 36–43. PMID: 32156840
  26. Smetkin A.A., Kirov M.Yu. Monitoring of venous saturation in anesthesiology and intensive care. General Reanimatology. 2008; 4 (4): 86–90 (in Russ.).
  27. Sirivella S., Gielchinsky I. Hemodynamic changes during off-pump coronary artery bypass graft surgery: experience using pericardial bands for target stabilization. World Journal of Cardiovascular Surgery. 2013; 3: 227–33.
  28. Bilotta F., Rosa G. Optimal glycemic control in neurocritical care patients. Crit. Care. 2012; 16 (5): 163.
  29. Schricker T., Sato H., Beaudry T., Codere T., Hatzakorzian R., Pruessner J.C. Intraoperative maintenance of normoglycemia with insulin and glucose preserves verbal learning after cardiac surgery. PLoS One. 2014; 9 (6): 99661.
  30. WenKui Y., Ning L., Jianfeng G., Weiqin L., Shaoqiu T., Zhihui T. et al. Restricted peri-operative fluid administration adjusted by serum lactate level improved outcome after major elective surgery for gastrointestinal malignancy. Surgery. 2010; 147 (4): 542–52. DOI: 10.1016/j.surg.2009.10.036
  31. Foucher C.D., Tubben R.E. Lactic Acidosis. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022. PMID: 29262026.
  32. Kalmar A.F., Allaert S., Pletinckx P., Maes J.W., Heerman J., Vos J.J. et al. Phenylephrine increases cardiac output by raising cardiac preload in patients with anesthesia induced hypotension. J. Clin. Monit. Comput. 2018; 32: 969–76. DOI: 10.1007/s10877-018-0126-3

About Authors

  • Dzhumber Ya. Khinchagov, Cand. Med. Sci., Anesthesiologist-Intensivist; ORCID
  • Mikhail M. Rybka, Dr. Med. Sci., Head of Department of Anesthesiology and Intensive Care Unit; ORCID
  • Koba V. Mumladze, Anesthesiologist-Intensivist; ORCID
  • Evgeny P. Golubev, Cand. Med. Sci., Senior Research; ORCID
  • Gennady V. Yudin, Cand. Med. Sci., Head of the Department of Resuscitation and Intensive Care; ORCID
  • Yuris Yu. Aidashev, Anesthesiologist-Intensivist; ORCID
  • Igor V. Vorozhka, Anesthesiologist-Intensivist; ORCID

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